Exposure Therapy For Anxiety And Eating Disorders

Last week on Real Health Radio I chatted with Sasha Gorrell about the concept of eating disorders as an anxiety disorder. It was an incredible conversation, so if you haven’t listened to it, I highly suggest that you do.

One of the ideas that we touched on early on is how, despite the difference among the different types of eating disorders, there are many commonalities. 

One commonality is the fear of the consequences of eating. Some of the fears can be:

• Putting on weight
• Digestive issues or feeling full
• That it will end in a binge
• Choking or vomiting
• Ingesting something toxic or unhealthy

So, regardless of the eating disorder, there’s a fear that something bad will happen as a consequence of eating.

Another commonality with all eating disorders, and this is a learned way of coping to deal with this fear of consequences, are behaviours that maintain the eating disorder. And these can collectively be known as avoidant coping behaviours.

Examples Of Avoidant Coping Behaviour

One definition I found describes avoidance coping as involving “cognitive and behavioural efforts oriented toward denying, minimising, or otherwise avoiding dealing directly with stressful demands.”

Let me give a couple of examples of what this can look like with eating disorders, touching on both the cognitive and behavioural aspects.

Let’s say that someone is afraid of eating a particular food, let me use pizza in this example. They know as part of recovery that they need to overcome the anticipation anxiety that just thinking about eating pizza creates. And they also need to go through the experience of actually eating the pizza.  

Tonight, there is an event that they are invited to, where they’ll meet friends to have dinner at a pizza place. It’s the perfect opportunity to challenge this fear. It’s also incredibly anxiety-inducing.

As the day goes on, the anxiety grows. Some of the avoidant behaviours that someone could entertain are:

• Going to the event, but saying they already ate so they don’t have to eat the pizza
• Cancelling on the event, saying that they feel unwell

There are ways that partial avoidance can happen. While they may eat the pizza, they change other habits to compensate for this:

• They reduce or skip other meals or snacks during the day
• They increase their exercise
• They only have a small amount of pizza, less than their normal dinner

So, while they did eat the food, the day or event was manipulated in a way to reduce the anxiety; ways that are continuing to maintain their eating disorder.

In terms of cognitive efforts of avoidance, these can be the messages they tell themselves to justify why they should avoid the pizza altogether or why it’s ok to eat less or compensate. Things like:

• I don’t even like pizza
• I bet there are plenty of people who have recovered without eating pizza
• I want to recover in a healthy way and pizza is not healthy
• It’s too hard to eat pizza at the moment, I can do it later on
• Lots of people eat less during the day if they are going out for dinner
• Lots of people do more exercise if they are going out for dinner
• My digestion just won’t cope with pizza, so I can’t eat much of it
• Just having some pizza is a win, so having one piece is fine
• There’s an obesity epidemic and it’s because of foods like pizza. I can have some, but one piece is fine 

Another common example with clients involves exercise or movement. Let’s say that the goal is to take time off from all forms of exercise. It has been a huge part of their eating disorder, as a way of modifying their weight and as a way of justifying being allowed to eat. 

Over time the exercise has both increased in its time and also its compulsion, so much so that they’ve been unable to have days off.

When they are in a pro-recovery mindset, they know that they need to have some time of complete abstinence. They have tried reducing it many times in the past and it simply doesn’t work. They know they need a complete break and that is the goal. 

So on the first day they are taking off, they wake up in a state of ambivalence. Part of them wants to take the time off as planned. But part of them is scared and anxious. As the day goes on, the anxiety increases.

So, behavioural avoidance in this case would be doing the exercise or movement.

The partial avoidance would be doing the exercise or movement, but doing less. Or compensating in other ways, like spending all their time standing, needlessly walking up and down stairs in their home, spending hours cleaning their house or any other ways of getting in movement.

And just like with the earlier pizza example, we add in the cognitive efforts of avoidance, the reasoning for why it’s ok to keep exercising, whether at the same amount as before or at a reduced amount:

• Everyone knows that exercise is healthy, I don’t think I need to give it up
• I’m much better at focusing at work once I’ve done my exercise
• I spend so much time inside, I need to have some outside time
• When I stop, the pain in my legs increases, so obviously stopping can’t be the right choice
• I’m playing football with friends and being more sociable is one of my goals
• I bet there are plenty of people who have recovered without stopping exercise
• I want to recover in a healthy way and being lazy and not moving isn’t healthy
• There’s an obesity epidemic and it’s because people are so sedentary these days. I can reduce what I was doing before, but stopping altogether is a bad idea
• I ate so much yesterday, I have to exercise today
• Exercising is my coping mechanism and it helps. It’s not like I’m doing heroin

These are just two examples of avoidance behaviour but this is a concept that comes up over and over again in eating disorder recovery. 

I should add that avoidance isn’t something solely connected to eating disorders. As humans, we all do it in many facets of our lives. And even when we become cognizant of the avoidance, this in and of itself doesn’t lead to a change. Because we often take short term comfort over long term pain.

So even when we know that avoidance isn’t going to lead to where we want to get to, in the moment we can come up with compelling reasons why now isn’t the right time or that maybe we don’t really want to change anyway.

Why Exposure Therapy Is The Antidote To Avoidance

During the conversation with Sasha Gorell, we talked about how if avoidance is at one end of the spectrum, exposure is at the other. Exposure here means taking action in ways that are pro-recovery. So why is exposure therapy so important for anxiety? Let me give two reasons.

The first is something I’ve already been talking about, which is its effect on psychology and the mind. Avoidance begets more avoidance. It doesn’t solve the problem and can have further negative effects on work, relationships and other areas of life. It also creates more anxiety and allows the problems to grow. 

What exposure therapy does is help you experience what it is like to not avoid. Some of the things that clients notice when doing this are:

• While the first time can be incredibly challenging, with numerous repetitions, the anxiety is greatly reduced. And typically this is much quicker than they imagined.
• There can be a sense of satisfaction at being able to do something they felt was impossible. It can help that see that other changes are also possible.

Exposure, with time, leads to neural rewiring. It leads to pathways in the brain changing. What used to be automatic and habitual, stops being so. And what used to feel strange, awkward or downright scary, now feels completely normal.

As I talk about with Sasha (as well as in this separate podcast) changes in the brain take time to occur. But they do occur, and it’s a great demonstration of both how plastic the brain is and also how impacted it becomes because of the eating disorder.

The second reason for the importance of exposure therapy is the impact that it can have on physiology. So many of the symptoms, thoughts and behaviour that emerge as part of an eating disorder are due to the body being in an energy-depleted state. And as the energy debt increases, so does the disorder.

Exposure, therefore, is important because it can help to reduce this debt. It can allow someone to:

• Eat more food in total
• Eat more often or have shorter gaps between meals
• Consume fear foods, which are typically calorie-dense
• Take time off exercise or reduce the amount that is being done
• Spend more time sleeping or lying down or sitting still

When these behaviours are done repeatedly, they can start to increase the amount of energy coming in while reducing the energy that is being used on exercise and movement. This creates more energy to repair the body and reduces the level of energy debt.

This leads, with time, to the improvement of physical symptoms (increased digestion, better quality sleep, resumption of menstruation, feeling warmer, more stable energy, better cognition and memory, to name a few), the reduction in frequency and intensity of eating disorder thoughts, and improvement in mood. 

Just like with the changes the exposure can have on psychology, there can be (and often is) a lag time for these improvements to be noticed. In the beginning, it can feel like it’s a lot of effort for no real gain. But with time, as the energy debt decreases, you do start to notice the benefits. And this can help to lead to an upward spiral, where pro-recovery actions lead to more pro-recovery actions.

[Note: Exposure therapy can be used for other issues, like trauma, that can also be connected to an eating disorder. This is something I cover in this podcast episode]

Exposure Therapy For Anxiety In Action

As I mentioned earlier, avoidance is a concept that comes up again and again in recovery. So below I want to give you some ideas for how to take action and make exposure a much more likely outcome. Rather than just knowing that you need to do it, but bailing out when the time comes, you’ll follow through and keep moving forward.

1. Set a specific goal

Too often it’s hoped that things will just get better on their own. That, with time, the anxiety will simply reduce and you’ll be able to do it. This won’t happen. Getting past this anxiety involves taking action and this will only happen if you are conscious of doing so. 

To make this a reality, set a goal. Articulate what this goal is and make it specific and tangible so you’ll know whether you have done it or not.

This helps so you know exactly what you need to do. But it also reduces the cognitive load, as the decision has been made in advance, so now it’s simply a matter of following through (which, obviously, is still easier said than done).

2. Pick a goal that will actually make a difference

Often the mantra in recovery is slow and steady, which makes sense from a place of safety and control. Unfortunately, though, it can lead to a lot of effort but with only a tiny upside (or none at all).

And if you are constantly feeling like you are trying really hard and are facing your fears and yet you are seeing no benefit, it’s easy to conclude that recovery will never happen.

As I covered in my recent conversation with Emily Troscianko, the intervention that you make is incredibly important. Not all goals are equal and many changes won’t actually amount to anything.

This means that when picking a goal, you need to go for something that will make a difference. And a difference in terms of its impact on your physiology, as well as moving you towards recovery in an appreciable way.

Examples of goals that won’t make much of a difference but can still be very challenging:

• Reducing your walking by five minutes
• Adding in a tablespoon of yoghurt to your breakfast 
• Having a single bite of pizza

I’m by no means saying that the above changes can’t be incredibly difficult. But if they are the only changes, it’s unlikely you’ll see any upside for all the energy you’re using to make them.

3. Connect with your values

One of the areas I work on early on with clients is looking at their values. They do this as a writing exercise and some of the questions are:

What do I want to be?

Who do I want to be?

What is important?

What really matters in life?

Imagine that you are in the future, ten years from now and you are looking back on your life as it is today. Complete these three sentences:

I spent too much time worrying about____.

I did not spend enough time doing things such as____.

If I could go back in time, what I’d do differently is____.

This is a list of core values. Look through this list and state what are your top five values (they don’t have to be in order).

From doing this exercise, what clients can see is how much their eating disorder is not in alignment with their values. And the impact that it is having is not negligible, it is clearly pulling them further away from where they want to be going.

The goal with this is then two-fold.

One, it’s to turn values that are often inspirational values into lived values. The aim is that if someone was to follow you with a video camera for a week, they could see that you are someone that lives by these values. 

Two, is to have these values be your north star or guiding light. When faced with ambivalence, anxiety or a tough choice, you think “what would a person with these values do in this moment” and you make a decision accordingly. 

To make these values more salient and front of mind, I will typically suggest that clients have their answers to the above questions in easy reach. I suggest reading it daily and using it as a reminder of why they’re doing what they’re doing. When they feel anxious or stuck, they read it again.

4. Plan alternative ways of spending your time

There is a saying in Acceptance And Commitment Therapy (ACT) to not create a goal that a dead person can do better than do can. So, for example, “don’t go walking” is a dead person’s goal because they will always be able to do this better than you can. 

The spirit of this idea is to plan how you are going to spend your time. So, if you’re not going to be walking, what are you going to be doing?

This is something that can come up a lot in recovery. That someone now has lots of time (or headspace) to fill and they don’t know what to do with themselves. And typically, if something doesn’t come in to fill this void, the old behaviour quickly will.

So, if the exposure that you are prioritising – like not walking or excising, not body checking, not weighing yourself, not eating vegetables, not drinking 1L of water first thing in the morning – is something that creates a void, the goal needs to be specific about what is filling that void.

5. Practice imagined exposure

An undervalued and under practised tool is that of imagined exposure. Why this is used so infrequently is probably connected to avoidance, because it can feel just as fearful to think of an event as it is to actually do it. But just like exposure is the antidote to avoidance, imagined exposure is also a powerful tool.

Let’s say that the goal is to eat pizza for dinner. Close your eyes and imagine yourself doing this activity and being successful doing it. Imagine yourself arriving at the table. Then sitting down and taking a bite. Then taking another bite. Then having another piece. And so on.

And while this is imagined, it should be connected to reality. Imagining yourself strolling up to the table without a care in the world and being completely relaxed is not realistic. Imagining yourself feeling uncomfortable but still being able to do it is realistic.

You can then imagine the scenario multiple times throughout the day in the run-up to the actual event, reinforcing the idea that you can be successful in meeting this goal.

Another way of doing this is with Tara Brach’s excellent RAIN meditation. It helps to connect with the emotions that are coming up, noticing them instead of trying to avoid them. It then connects with values, something I’ve already covered. And then gets you to decide on a specific action you are going to take.

(I plan to write a whole article on the benefits of RAIN, but that’s for another day).

 6. Have an accountability partner

The final suggestion I would make is to have an accountability partner.

I mentioned earlier that as humans we’re great at rationalising the choices that we make. It’s like our minds contain this little lawyer that is always arguing our case and why we are justified in what we did.

But we are typically less successful when we try and argue this case outside of our head. Especially if we are reneging on a goal that we said we were going to do. One that will help us move forward and is in alignment with our values.

When someone else is involved, we tend to perform better and keep to our promises. And when genuine obstacles do arise, we’re better at finding solutions rather than having them stop us in our tracks.

So with this accountability partner, you can check in daily or weekly or fortnightly; whatever is the right amount for keeping you on track. Email or message them what your goals are. Then the next time you message you can include: what was accomplished, what you learned, any challenges or obstacles you faced, and then what is the next goal. 

If you need support in between, they can also provide this. They can be both your cheerleader and your reality checker, supporting you in the way that is most needed at the point you’re at. 

Having an accountability partner greatly increases the likelihood that you’ll follow through and that you’ll reach (and stay at) a place of full recovery.

Would You Like Help?

Recovery is challenging. And often this isn’t so much about not knowing what to do, it’s because you know what you do need to do, but struggle to get yourself to do it.

My final suggestion above was to have an accountability partner. This is one of the roles I play for clients. I help them to set goals that are going to move the needle and have a positive impact on recovery. And I then help those goals to come into reality, rather than something that continues to feel out of reach, further blossoming the anxiety. 

I’m a leading expert and advocate for full recovery. I’ve been working with clients for over 15 years and understand what needs to happen to recover.

I truly believe that you can reach a place where the eating disorder is a thing of the past and I want to help you get there. If you want to fully recover and drastically increase the quality of your life, I’d love to help.

Want to get a FREE online course created specifically for those wanting full recovery? Discover the first 5 steps to take in your eating disorder recovery. This course shows you how to take action and the exact step-by-step process. To get instant access, click the button below.